Laserfiche WebLink
BOARD OF TRUSTEES SAN JOAOUIN LOCAL HEALTH DISTRICT SERVING <br /> * At Crow,Pres. San Joaquin County <br /> Earl Pimentel,Vice Pres. 1601 East Hazelton Avenue city or Manteca <br /> Tommy Joyce,Secy. Stockton, California95205 City of Escalon <br /> James F.Culbertson City of Lodi <br /> John 0.Mast,M.D. JOGt KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Tracy <br /> Virginia Mathews City of Ripon <br /> Thomas Schubert,D.V.M. ENVIRONMENTAL HEALTH DIVISION San Joaquin County <br /> Daphne Shaw (20 9) 468-3420 City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County <br /> AUTHC3F;z I z^T I C71V co RELEASE <br /> - ANALYTICAL RESULTS <br /> - <br /> GEOTECHNICAL DATA <br /> - - ENVIRONMENTAL/SITE ASSESSMENT INFORMATION , <br /> 1 <br /> I , THE UNDERSIGNED OWNER ANC)/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT--57Q/ 4A G Wel rvla,, 461 A C 40 ( <br /> (STREET ADDRESS) (CITy) <br /> HEREBY AUTHORIZE 19r&2,0k1 et A dL4 <br /> (LABORATORY or CONSULTANT) <br /> TO RELEASE ANY AND ALL ANALYTICAL RESULTE , GEOTECHNICAL DATA AND/OR <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION TO THE SAN JOAQUIN LOCAL HEALTH <br /> DISTRICT AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED. <br /> TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: r d <br /> (IF APPLICABLE) <br /> OWNER/OPERATOR: ✓, h ! A I K G <br /> (PLEASE PRlN1} (TITLE) <br /> (SIGNATURE) <br /> ADDRESS: r -1='J "9Q, 01F <br /> (NAILING ADDRESS) <br /> 64 19 o3 <br /> (CITY) (S ATE) (ZIP) <br /> PHONE: 4 / ) <br /> t <br /> DATE: <br /> EH 23 041 Revised 1/89 <br /> Administratlon Clinical Services I nvironmental Health Public Health Nursing <br /> 468-3400 468-3830 468-3420 468-3860 <br /> Air Pollution Community Services Laboratory Wic <br /> 468-3470 468-3820 468-3460 468-3280 <br /> AIDS Information 468- 820 <br />